Percutaneous Nephrolithotomy (PCNL)

PCNL is one of the most technically demanding procedures in endourology, because it combines precise imaging guidance, endoscopic skill, and a clear understanding of when a less invasive approach is sufficient and when direct percutaneous access is required.

My approach always starts with the overall picture: stone size and shape, its location within the collecting system, density on CT, kidney anatomy, presence of infection, renal function, and the patient’s own preferences. Stone size matters, but it is not the only decision factor.

I place particular emphasis on honest counselling: that a large or staghorn stone may require more than one session, that the choice of fragmentation technology is a tool rather than a guarantee of outcome, and that drainage strategy after the procedure is decided intraoperatively — not fixed in advance as a general rule.

• Treatment decisions rely on multiple factors, not stone size alone.
• Staged treatment for complex stones is not failure — it is safe strategy.
• Lithotripsy technology supports the procedure; it does not replace it.
• Treatment does not end with stone removal — recurrence prevention matters equally.

PCNL (Percutaneous Nephrolithotomy) is an endourological procedure in which a controlled percutaneous tract is created from the skin to the kidney’s collecting system. Through this tract a nephroscope is introduced, allowing direct visualisation of the stone, fragmentation where needed, and extraction of the stone material or its fragments.

The internationally established term is Percutaneous Nephrolithotomy (PCNL). In everyday use, PCNL involves percutaneous access to the renal collecting system, fragmentation where required, and extraction/evacuation of the stone or its fragments.

Treatment choice for a kidney stone also depends on:

Additional indications include partial or complete staghorn stones, multiple large renal calculi, stones unfavourable for ESWL, selected lower-pole stones, and cases where RIRS would likely require multiple stages.

Staghorn calculi can occupy the renal pelvis and multiple calyces, forming a branching shape. They may be associated with large stone burden, obstruction, recurrent infection, and damage to renal function.

PCNL is a core treatment approach for many complex or staghorn stones. However, a single PCNL does not always suffice, and the entire stone burden is not always removed in one session.

PCNL is generally preferred for larger/complex stone burdens because it allows direct access and efficient extraction. RIRS is an excellent option for many smaller/moderate stone burdens, but as burden increases it may require staged treatment. The “less invasive” method is not always the most effective choice for very large stone burden. See our page on High Power Laser Kidney Stone Lithotripsy (RIRS).

The effectiveness of ESWL depends on stone size, location, hardness, and anatomical factors. For very large or complex stones it may be substantially less efficient. This does not mean ESWL is obsolete — it remains an appropriate option for selected smaller/favourable stones. See our page on Extracorporeal Shock Wave Lithotripsy (ESWL).

PCNL involves percutaneous access directly into the kidney. Ureteroscopic lithotripsy (URS) is performed retrogradely, through the urethra-bladder-ureter, without a percutaneous tract. These are two different access techniques that should not be confused. See our page on Endoscopic Ureteral Lithotripsy.

At Lefkos Stavros, the Swiss LithoClast® Trilogy is available, an intracorporeal lithotripsy system for fragmentation and suction of stones during percutaneous nephrolithotomy (PCNL).

Through a single probe it can combine ultrasonic energy, ballistic energy, and suction, using these energy forms simultaneously or independently as needed. This allows fragmentation and simultaneous removal of stone material.

Technical details such as frequency, pressure, suction settings, or probe dimensions are not provided — these concern the surgical team, not patient-facing content.

Neither technology is presented as universally superior — the choice depends on access method and surgical strategy.

Stone composition affects fragmentation. Potentially harder stones include certain calcium oxalate monohydrate, brushite, and cystine stones. However, exact composition is often not definitively known before surgery — CT density and history can provide clues, without forming a rigid HU-based treatment algorithm.

Current EAU guidance supports pre-operative CT to understand stone burden, collecting-system anatomy, kidney anatomy, surrounding organs, and safe access considerations. Contrast may be used when indicated — not every patient requires the identical contrast protocol.

Non-contrast CT provides information on the number/location of stones, stone burden and density, without being a perfect diagnostic tool for stone composition.

PCNL planning considers the kidney’s relationship with structures such as the colon, liver, spleen, pleura/lung, and renal vessels, without this page providing puncture instructions.

Current evidence indicates both can be safe and effective. Neither is presented as universally superior.

PCNL access may be guided using ultrasound, fluoroscopy, or a combination of both. Current evidence supports both approaches when appropriately used — we do not state here which is used routinely at Lefkos Stavros without verified confirmation.

When fluoroscopy is used, current ALARA-type radiation protection principles are applied. We do not claim zero radiation exposure unless the actual workflow is verified.

“Mini-PCNL” refers broadly to percutaneous nephrolithotomy using smaller-calibre instruments compared with standard PCNL. Potential advantages of smaller tracts may include lower bleeding burden, but possible trade-offs can include longer fragmentation/extraction time for larger stone burdens.

For complex or staghorn stones, more than one percutaneous access tract to different calyces may occasionally be needed. This can improve access but may also increase invasiveness and bleeding risk — it is not routine practice for every case.

What Is ECIRS?

Endoscopic Combined Intrarenal Surgery (ECIRS) combines selected percutaneous access with retrograde flexible ureteroscopy during a coordinated procedure. It may help in selected complex stones, without being presented as mandatory or universally superior.

Before PCNL, clinically significant urinary infection is assessed and treated according to current guidance, without reference here to a specific drug, dose, or duration.

Beyond a standard mid-stream urine culture, renal pelvic urine culture and/or stone culture can provide useful microbiological information. Current evidence suggests these may predict post-PCNL septic complication risk better than mid-stream culture alone.

Creating a percutaneous tract through the kidney carries a recognised bleeding risk. Possible outcomes include transient haematuria, a drop in haemoglobin, transfusion in selected cases, angiographic treatment more rarely, and surgical treatment rarely in major bleeding.

Bleeding may rarely present after discharge. Warning symptoms requiring evaluation include significant haematuria, clots, dizziness, weakness, flank pain, or a fainting episode.

Delayed bleeding can occasionally result from a renal artery pseudoaneurysm or an arteriovenous fistula. Selected cases can be treated with angiographic embolisation. No incidence figure is stated here without full sourcing.

Depending on anatomy and access site, particularly with selected upper-pole/supracostal access, thoracic complications such as pleural injury, hydrothorax, or pneumothorax can occur, though this page does not teach access technique. In uncommon circumstances, adjacent organs such as the colon, liver, or spleen may be injured.

PCNL does not guarantee complete stone clearance in every patient. Residual fragments may depend on stone burden, anatomy, the number of calyces involved, bleeding/visibility, and safety considerations during the procedure.

Further options may include observation in selected circumstances, a second-look PCNL, RIRS, ESWL, or other treatment depending on fragment characteristics.

We do not use a single generic “stone-free rate” here without context. Whenever a percentage is quoted in the literature, it must define imaging modality, timing, stone burden, the definition of a clinically insignificant residual fragment, procedure type, and source — otherwise a single figure is misleading.

No. After PCNL, drainage strategy can include:

Tubeless & Totally Tubeless PCNL

Tubeless PCNL generally refers to omitting a nephrostomy tube in appropriately selected, uncomplicated cases. It does not necessarily mean no ureteral stent or no drainage at all.

Totally tubeless PCNL may mean no nephrostomy and no ureteral JJ stent in selected uncomplicated cases. Current EAU guidance supports tubeless/totally tubeless approaches in appropriately selected patients, without implying that everyone should have a totally tubeless PCNL.

JJ Stent vs Nephrostomy

PCNL generally requires appropriate operative anaesthesia, usually general anaesthesia, depending on protocol, patient, and procedure. It is not an office procedure.

Hospital stay is not the same for every patient — it depends on complexity, bleeding, infection, drainage strategy, residual stones, and overall condition. Current evidence permits ambulatory PCNL in selected cases, without this being routine for everyone.

Recovery includes mobilisation, gradual return of oral intake, discomfort management, monitoring of haematuria, care of any nephrostomy/JJ stent, and wound care. There is no single fixed timetable for return to work, driving, or exercise — it is individualised.

Recovery Timeline

PCNL aims to remove problematic stone burden while preserving as much functional kidney tissue as possible. The final outcome for renal function depends on pre-existing function, obstruction, infection, stone burden, the operative course, and comorbidities — improvement in renal function is not promised in every case.

Solitary Kidney

PCNL can be considered in selected solitary-kidney patients when indicated, with especially careful planning for renal preservation, bleeding, and drainage. It is not automatically a contraindication.

Obesity & Complex Anatomy

These can affect imaging, positioning, access, and anaesthesia. PCNL is not considered impossible based on BMI alone.

Pregnancy

Management of renal stones in pregnancy follows a distinct pathway balancing mother, fetus, radiation, infection, and obstruction. Elective PCNL is not standard treatment in pregnancy.

After stone extraction, stone analysis can help understand the cause and inform recurrence prevention. If the Trilogy’s collection system is referenced, this remains factual — without implying that every recovered fragment is automatically analysed in every case.

For recurrent/high-risk stone formers, prevention may involve stone analysis, blood testing, urine testing, selected 24-hour urine studies, and targeted dietary/medical prevention. We do not provide generic “drink X litres” advice without context here. See our page on Kidney Stones.

Stone culture looks for microorganisms, while stone analysis determines chemical/mineral composition — they answer different clinical questions.